CMS/Standard 2004 2008§482.22 Condition of Participation: Medical staff

The hospital must have an organized medical staff that operates under bylaws approved by the governing body and is responsible for the quality of medical care provided to patients by the hospital.

Interpretive GuidelinesThe hospital may have only one medical staff for the entire hospital (including all campuses, provider -based locations, satellites, remote locations, etc.). The medical staff must be organized and integrated as one body that operates under one set of bylaws approved by the governing body. These medical staff bylaws must apply equally to all practitioners within each category of practitioners at all locations of the hospital and to the care provided at all locations of the hospital. The single medical staff is responsible for the quality of medical care provided to patients by the hospital.

Interpretive GuidelinesThe hospital may have only one medical staff for the entire hospital (including all campuses, provider-based locations, satellites, remote locations, etc.). The medical staff must be organized and integrated as one body that operates under one set of bylaws approved by the governing body. These medical staff bylaws must apply equally to all practitioners within each category of practitioners at all locations of the hospital and to the care provided at all locations of the hospital. The single medical staff is responsible for the quality of medical care provided to patients by the hospital.

§482.22(a) Standard: Composition of the Medical Staff

The medical staff must be composed of doctors of medicine or osteopathy and, in accordance with State law, may also be composed of other practitioners appointed by the governing body.

Interpretive GuidelinesThe medical staff must at a minimum be composed of physicians who are doctors of medicine or doctors of osteopathy. In addition, the medical staff may include other practitioners included in the definition in Section 1861(r) of the Social Security Act of aphysician:

Doctor of medicine or osteopathy;

Doctor of dental

surgery or of dental medicine;

Doctor of podiatric medicine;

Doctor of optometry; and a

Chiropractor.In all cases the practitioners included in the definition of a physician must be legally authorized to practice within the State where the hospital is located and providing services within their authorized scope of practice. In addition, in certain instances the Social Security Act and regulations attach further limitations as to the type of hospital services for which a practitioner may be considered to be a “physician.” See§482.12(c)(1) for more detail on these limitations.

The governing body has the flexibility to determine whether other types of practitioners included in the definition of a physician are eligible for appointment to the medical staff.

Furthermore, the governing body has the authority, in accordance with State law, to appoint some types of non-physician practitioners, such as nurse

practitioners, physician assistants, certified registered nurse anesthetists, and midwives, to the medical staff.

Practitioners, both physicians and non-physicians, may be granted privileges to practice at the hospital by the governing body for practice activities authorized within their State scope of practice without being appointed a member of the medical staff.

§482.22(a)(1) The medical staff must periodically conduct appraisals of its members.

Interpretive GuidelinesThe purpose of the appraisal is for the medical staff to determine the suitability of individual members for continued membership on the medical staff and to determine if that individual practitioner’s clinical privileges should be continued, discontinued, revised, or otherwise changed.The medical staff appraisal procedures must evaluate each individual member’s training, experience, and demonstrated competence as established by the hospital [Quality Assessment and Performance

The medical staff must at regular intervals appraise the qualifications of all practitioners appointed to the medical staff/granted medical staff privileges. In the absence of a State law that establishes a timeframe for periodic reappraisal, a hospital’s medical staff must conduct a periodic appraisal of each practitioner. CMS recommends that an appraisal be conducted at least every 24 months for each practitioner.

The purpose of the appraisal is for the medical staff to determine the suitability ofcontinuing the medical staff membership or

Improvement] QAPI program, credentialing process, and the member’s adherence to medical staff bylaws and rules and regulations.The medical staff bylaws must establish the frequency and other factors that determine when appraisals of medical staff members will be conducted.After the medical staff conducts its appraisal of individual members, the medical staff makes recommendations to the governing body for continued medical staff membership that are specific to the type of appointment and extent of clinical privileges, and the governing body takes final appropriate action. A separate credentials file must be maintained for each medical staff member.

Survey Procedures Determine that

the medical staff has a system in place that is used to periodically appraise its current members and their qualifications in accordance with approved medical staff bylaws and State law

privileges of each individual practitioner, todetermine if that individual practitioner’s membership or privileges should be continued, discontinued, revised, or otherwise changed.

The medical staff appraisal procedures must evaluate each individual practitioner’squalifications and demonstrated competencies to perform each task or activity within theapplicable scope of practice or privileges for that type of practitioner for which he/shehas been granted privileges. Components of practitioner qualifications anddemonstrated competencies would include at least: current work practice, specialtraining, quality of specific work, patient outcomes, education, maintenance ofcontinuing education, adherence to medical staff rules, certifications, appropriate licensure, and currency of compliance with licensure requirements.

In addition to the periodic appraisal of members, any procedure/task/activity/pr

requirements. Determine that

the medical staff bylaws specify the timeframes for the periodic appraisal.

Verify that an outcome-oriented appraisal system is conducted for all individual members of the medical staff.

Determine how the medical staff conducts the periodic appraisals of any current member of the medical staff who has not provided patient care at the hospital or who has not provided care for which he/she is privileged to patients at the hospital during the appropriate evaluation time frames. Is this method in accordance with State law and the hospital’s written criteria for medical staff membership and for granting privileges?

ivilege requested by a practitioner that goes beyond the specified list of privileges for that particular category of practitioner requires an appraisal by the medical staff and approval by the governing body. The appraisal must consider evidence of qualifications and competencies specific to the nature of the request. It must also consider whether theactivity/task/procedure is one that the hospital can support when it is conducted within the hospital. Privileges cannot be granted for tasks/procedures/activities that are not conducted within the hospital, regardless of the individual practitioner’s ability to perform them.

After the medical staff conducts its reappraisal of individual members, the medical staffmakes recommendations to the governing body to continue, revise, discontinue, limit, orrevoke some or all of the practitioner’s privileges, and the governing body takes final appropriate action.

A separate credentials file must be maintained for each medical staff member. The

hospital must ensure that the practitioner and appropriate hospital patient careareas/departments are informed of the privileges granted to the practitioner, as well as of any revisions or revocations of the practitioner’s privileges. Furthermore, whenever apractitioner’s privileges are limited, revoked, or in any way constrained, the hospitalmust, in accordance with State and/or Federal laws or regulations, report thoseconstraints to the appropriate State and Federal authorities, registries, and/or data bases, such as the National Practitioner Data Bank.

Survey Procedures Determine whether

the medical staff has a system in place that is used to reappraise each of its current members and their qualifications at regular intervals, or, if applicable, as prescribed by State law.

Determine whether the medical staff by-laws identify the process and criteria to be used for the periodic appraisal.

Determine whether the criteria used for reevaluation comply with the requirements of this section, State law and hospital bylaws, rules, and regulations.

Determine whether the medical staff has a system to ensure that practitioners seek approval to expand their privileges for tasks/activities/procedures that go beyond the specified list of privileges for their category of practitioner.

Determine how the medical staff conducts the periodic appraisals of any current member of the medical staff who has not provided patient care at the hospital or who has not provided care for which he/she is privileged to patients at the hospital during the appropriate evaluation time frames. Is this method in accordance with State law and the hospital’s written criteria for medical

staff membership and for granting privileges?

§482.22(a)(2) The medical staff must examine credentials of candidates for medicalstaff membership and make recommendations to the governing body on the appointment of the candidates.

Interpretive GuidelinesThere must be a mechanism established to examine credentials of individual prospective members (new appointments or reappointments) by the medical staff. The credentials examined include at least:

A request for clinical privileges;

Current licensure;

Training and professional education;

Documented experience; and

Supporting references of competence.

The medical staff makes recommendations to the governing body for each new member and for reappointment of members that are specific to type of appointment and extent of the individual practitioner’s specific rather than general clinical privileges, and then the governing body takes final appropriate action. A separate credentials file must be maintained for each individual medical staff member or applicant.

Interpretive GuidelinesThere must be a mechanism established to examine credentials of individual prospective members (new appointments or reappointments) by the medical staff. The individual’scredentials to be examined must include at least:

A request for clinical privileges;

Evidence of current licensure;

Evidence of training and professional education;

Documented experience; and

Supporting references of competence.

The medical staff may not make its recommendation solely on the basis of the presence or absence of board certification, but must consider all of the elements above. However, this does not mean that the medical staff is prohibited from requiring in its bylaws board certification when considering a MD/DO for medical staff membership or privileges; only that such

certification may not be the only factor that the medical staff considers.

The medical staff makes recommendations to the governing body for each candidate for medical staff membership/privileges that are specific to type of appointment and extent of the individual practitioner’s specific clinical privileges, and then the governing body takes final appropriate action.

A separate credentials file must be maintained for each individual medical staff member or applicant. The hospital must ensure that the practitioner and appropriate hospital patient care areas/departments are informed of the privileges granted to the practitioner.

Survey Procedures Determine whether

the medical staff bylaws identify the process and criteria to be used for the evaluation of candidates for medical staff membership/privileges.

Determine whether the criteria used for

evaluation comply with the requirements of this section, State law, and hospital bylaws, rules, and regulations.

Determine whether the medical staff has a system to ensure that practitioners seek approval to expand their privileges for tasks/activities/procedures that go beyond the specified list of privileges for their category of practitioner.

§482.22(b) Standard: Medical Staff Organization and Accountability

The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients.(1) The medical staff must be organized in a manner approved by the governing body.(2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy.(3)The responsibility for organization and conduct

Interpretive GuidelinesThe medical staff must be accountable to the hospital’s governing body for the quality of medical care provided to the patients. The organization of the medical staff must comply with these requirements.

Survey Procedures Verify that the

medical staff has a formalized organizational structure, that lines of function and responsibility are delineated between the governing body and other parts of

Interpretive GuidelinesThe medical staff must be accountable to the hospital’s governing body for the quality of medical care provided to the patients. The organization of the medical staff must comply with these requirements.

Survey Procedures Verify that the

medical staff has a formalized organizational structure, that lines of function and responsibility are delineated between the governing body and other parts of the organization,

of the medical staff must be assigned only to an individual doctor of medicine or osteopathy or, when permitted by State law of the State in which the hospital is located, a doctor of dental surgery or dental medicine.

the organization, and that the governing body has sanctioned its approval on the organizational structure and relationships.

If there is an active executive committee, verify that a majority of the members are doctors of medicine or osteopathy.

Verify that an individual doctor of medicine or osteopathy is responsible for the conduct and organization of the medical staff through review of the organizational structure and interviews with members of the medical staff.

and that the governing body has sanctioned its approval on the organizational structure and relationships.

If there is an active executive committee, verify that a majority of the members are doctors of medicine or osteopathy.

Verify that an individual doctor of medicine or osteopathy is responsible for the conduct and organization of the medical staff through review of the organizational structure and interviews with members of the medical staff.

§482.22(c) Standard: Medical Staff Bylaws

The medical staff must adopt and enforce bylaws to carry out its responsibilities.The bylaws must:

Interpretive GuidelinesThe medical staff must develop and adopt bylaws, and after the hospital’s governing body approves the bylaws, the medical staff must enforce its bylaws.

Survey Procedures Verify that the

medical staff have bylaws.

Verify that the bylaws describe a

Interpretive GuidelinesThe medical staff must regulate itself by bylaws that are consistent with the requirements of this and other CoPs that mention medical staff bylaws, as well as State laws. The bylaws must be enforced and revised as necessary.

Survey Procedures Verify that the

medical staff have

mechanism for ensuring enforcement of its provisions along with rules and regulations of the hospital.

Verify that the medical staff enforce the bylaws.

bylaws that comply with the CoPs and State law.

Verify that the bylaws describe a mechanism for ensuring enforcement of its provisions along with rules and regulations of the hospital.

Verify that the medical staff enforce the bylaws.

§482.22(c)(1) Be approved by the governing body.

Interpretive GuidelinesThe medical staff must regulate itself by bylaws, rules and regulations that are consistent with acceptable medical staff practices. The bylaws must be enforced and revised as necessary. Medical staff bylaws and any revisions of those bylaws must be submitted to the governing body for approval. The governing body has the authority to approve or disapprove bylaws suggested by the medical staff. The bylaws and any revisions must be approved by the governing body before they are considered effective.

Survey ProceduresVerify the medical staff is operating under current medical staff bylaws, rules, and

Interpretive GuidelinesMedical staff bylaws and any revisions of those bylaws must be submitted to the governing body for approval. The governing body has the authority to approve or disapprove bylaws suggested by the medical staff. The bylaws and any revisions must be approved by the governing body before they are considered effective.

Survey ProceduresVerify that the medical staff bylaws have been approved by the medical staff and the governing body.

policies that are in accordance with Federal and State laws and regulations and accepted standards of practice and have been approved by the medical staff and the governing body.

§482.22(c)(2) Include a statement of the duties and privileges of each category of medical staff (e.g., active, courtesy, etc.)

Interpretive GuidelinesThe medical staff bylaws must include a statement of the duties, responsibilities, and privileges of each category of medical staff.

Survey ProceduresVerify that the bylaws specify the roles and responsibilities of each category of practitioner on medical staff.

Interpretive GuidelinesThe medical staff bylaws must state the duties and scope of medical staff privileges each category of practitioner may be granted. Specific privileges for each category must clearly and completely list the specific privileges or limitations for that category of practitioner. The specific privileges must reflect activities that the majority of practitioners in that category can perform competently and that the hospital can support.Although the medical staff bylaws must address the duties and scope for each category of practitioner, this does not mean that each individual practitioner within the category may automatically be granted the full range of privileges. It cannot be assumed that every practitioner can perform every task/activity/privilege that is specified for the applicable category of practitioner. The

individual practitioner’s ability to perform each task/activity/privilege must be individually assessed.

Survey Procedures Determine whether the bylaws specify the duties and scope of medical staff privileges for each category of practitioner eligible for medical staff membership or privileges.

§482.22(c)(3) Describe the organization of the medical staff.

Interpretive GuidelinesThe medical staff bylaws must describe the organizational structure of the medical staff, and lay out the rules and regulations of the medical staff to make clear what are acceptable standards of patient care for all diagnostic, medical, surgical, and rehabilitative services.

Survey Procedures Verify that the

bylaws specify the organization and structure of the medical staff, and a mechanism that delineates accountability to the governing body.

Verify that the bylaws describe who is responsible for regularly

Interpretive Guidelines The medical staff bylaws must describe the organizational structure of the medical staff, and lay out the rules and regulations of the medical staff to make clear what are acceptable standards of patient care for all diagnostic, medical, surgical, and rehabilitative services.

Survey Procedures Verify that the

bylaws specify the organization and structure of the medical staff, and a mechanism that delineates accountability to the governing body.

Verify that the bylaws describe who is responsible for regularly

scheduled review and evaluation of the clinical work of the members of the medical staff and describe the formation of medical staff leadership.

scheduled review and evaluation of the clinical work of the members of the medical staff and describe the formation of medical staff leadership.

§482.22(c)(4) Describe the qualifications to be met by a candidate in order for themedical staff to recommend that the candidate be appointed by the governing body.

Interpretive GuidelinesThe medical staff bylaws must describe the qualifications to be met by a candidate for membership on the medical staff. The medical staff then recommends individual candidates that meet those requirements to the governing body for appointment to the medical staff.

Survey ProceduresVerify that the medical staff bylaws describe the qualifications such as licensure, specifictraining, experience, current competence, judgment, character, and health status to be met by an individual candidate for the medical staff to recommend appointment or reappointment.

Interpretive Guidelines The medical staff bylaws must describe the qualifications to be met by a candidate formedical staff membership/privileges in order for the medical staff to recommend the candidate be approved by the governing body. The bylaws must describe the privileging process to be used in the hospital. The process articulated in the medical staff bylaws must include criteria for determining the privileges that may be granted to individualpractitioners and a procedure for applying the criteria to individual practitioners thatconsiders:

Individual character;

Individual competence;

Individual training; Individual

experience; and Individual

judgment.

The medical staff may

not rely solely on the fact that a MD/DO is, or is not, board-certified in making a judgment on medical staff membership. This does not mean that the medical staff is prohibited from requiring board certification when considering aMD/DO for medical staff membership; only that such certification is not the only factor that the hospital considers. After analysis of all of the criteria, if all criteria are met except for board certification, the medical staff has the discretion to not recommend that individual for medical staff membership/privileges.

The bylaws must apply equally to all practitioners in each professional category of practitioners.

The medical staff then recommends individual candidates that meet those requirements to the governing body for appointment to the medical staff.

Survey Procedures Verify that there

are written criteria for appointments to the medical staff and granting of medical staff

privileges. Verify that granting

of medical staff membership or privileges, is based upon an individual practitioner’s meeting the medical staff’s membership/privileging criteria.

Verify that at a minimum, criteria for appointment to the medical staff/granting of medical staff privileges are individual character, competence, training, experience, and judgment.

Verify that written criteria for appointment to the medical staff and granting of medical staff privileges are not dependent solely upon certification, fellowship, or membership in a specialty body or society.

§482.22(c)(5) Include a requirement that a physical examination and medical history be done no more than 7 days before or 48 hours after an admission for each patient by a doctor of medicine or osteopathy,

Interpretive GuidelinesThe Medical Staff bylaws must include a requirement that a physical examination and medical history (H & P) must be performed on each patient by a MD, DO or

Interpretive Guidelines (i)The purpose of a medical history and physical examination (H&P) is to determine whether there is anything in the patient's overall condition that would affect the planned course of the

or, for patients admitted only for oromaxillofacial surgery, by an oromaxillofacial surgeon who has been granted such privileges by the medical staff in accordance with State law.

(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08) [The bylaws must:]482.22(c)(5) Include a requirement that --(i) A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oromaxillofacial surgeon, or other

for patients admitted only for oromaxillofacial surgery, by an oromaxillofacial surgeon. The practitioner who performs the H & P must have been granted such privileges by the medical staff in accordance with State law.

The H & P must be performed by an MD/DO or oromaxillofacial surgeon, for patients receiving oromaxillofacial surgery, no more than 7 days prior to hospital admission/outpatient surgery or 48 hours after hospital admission but prior to surgery/outpatient surgery.

Admission H & PA H& P would meet the CMS requirements that a H & P be “performed no more than 7 days prior to admission or within 48 hours after admission,” if:

The H & P was performed within 30 days prior to the hospital admission; AND

An appropriate assessment performed by the MD/DO, which must include a

patient's treatment, such as a medication allergy, or a new or existing comorbid condition that requires additional interventions to reduce risk to the patient.

The Medical Staff bylaws must include a requirement that an H&P be completed and documented for each patient no more than 30 days prior to or 24 hours after hospital admission or registration, but prior to surgery or a procedure requiring anesthesia services. The H&P may be handwritten or transcribed, but always must be placed within the patient’s medical record within 24 hours of admission or registration, or prior to surgery or a procedure requiring anesthesia services, whichever comes first.

An H&P is required prior to surgery and prior to procedures requiring anesthesia services, regardless of whether care is being provided on an inpatient or outpatient basis. (71 FR 68676) An H&P that is completed within 24 hours of the patient’s admission or registration, but after the surgical procedure, procedure requiring anesthesia, or other

qualified licensed individual in accordance with State law and hospital policy.

(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)[The bylaws must:]482.22(c)(5) - [Include a requirement that --](ii) An updated examination of the patient, including any changes in the patient's condition, be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration. The updatedexamination of the patient, including any changes in the patient's condition, must be completed and documented by a physician (as

physical assessment of the patient to update any components of the patient’s current medical status that may have changed since the prior H & P or to address any areas where more current data is needed, was completed within 7 days prior to admission or 48 hours after admission, but prior to surgery, confirming that the necessity for the procedure or care is still present and the H & P is still current. The physician uses his/her clinical judgment based on his/her assessment of the patient’s condition, and any co-morbidities, in relation to the reason the patient was admitted or to the surgery to be performed, when deciding what depth of assessment needs to be performed

procedure requiring an H&P would not be in compliance with this requirement.

The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy.

Section 1861(r) defines a physician as a:

Doctor of medicine or osteopathy;

Doctor of dental surgery or of dental medicine;

Doctor of podiatric medicine;

Doctor of optometry; or a

Chiropractor.

In all cases the practitioners included in the definition of a physician must be legally authorized to practice within the State where the hospital is located and providing services within their authorized scope of practice. In addition, in certain instances the Social Security Act attaches further limitations as to the type of hospital

defined in section 1861(r) of the Act), an oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy.

and what information needs to be included in the update note; AND

The physician or other individual qualified to perform the H & P writes an update note addressing the patient’s current status and/or any changes in the patient’s status, regardless of whether there were any changes in the patient’s status, within 7 days prior to, or within 48 hours after admission, but prior to surgery. The update note must be on or attached to the H & P, AND

The H & P, including all updates and assessments, must be included within 48 hours after admission, but prior to surgery (except in emergency situations), in the patient’s medical record for this admission.

services for which a practitioner is considered to be a “physician.”

Other qualified licensed individuals are those licensed practitioners who are authorized in accordance with their State scope of practice laws or regulations to perform an H&P and who are also formally authorized by the hospital to conduct an H&P. Other qualified licensed practitioners could include nurse practitioners and physician assistants.

More than one qualified practitioner can participate in performing, documenting, and authenticating an H&P for a single patient. When performance, documentation, and authentication are split among qualified practitioners, the practitioner who authenticates the H&P will be held responsible for its contents. (71 FR 68675)

A hospital may adopt a policy allowing submission of an H&P prior to the patient’shospital admission or registration by a physician who may not be a member of the

If a H & P meets all these requirements within 7 days prior to admission, or within 48 hours after admission, the H & P meets the provisions of the regulation with regard to justifying the admission and meeting the time restrictions on the currency of the H & P.

Outpatient Surgery H & PFurthermore, a H & P would meet the CMS requirement at §482.51(b)(1) that “There must be a complete history and physical work-up in the chart of every patient prior to surgery…” if:

The H & P was performed within 30 days prior to the outpatient surgery; AND

An appropriate assessment performed by the MD/DO, which should include a physical examination of the patient to update any components of the patients current medical status that may have changed since the prior H & P or to address any areas

hospital's medical staff or who does not have admitting privileges at that hospital, or by a qualified licensed individual who does not practice at that hospital but is acting within his/her scope of practice under State law or regulations. Generally, this occurs where the H&P is completed in advance by the patient’s primary care practitioner. (71 FR 68675)

When the H&P is conducted within 30 days before admission or registration, an updatemust be completed and documented by a licensed practitioner who is credentialed and privileged by the hospital’s medical staff to perform an H&P. (71 FR 68675) (See discussion of H&P update requirements at 42 CFR 482.22(c)(5)(ii).)

Surveyors should cite noncompliance with the requirements of 42 CFR482.22(c)(5) for failure by the hospital to comply with any of this standard's components.

Survey Procedures (i) Review the medical

staff bylaws to determine whether they require that a

where more current data is needed, was completed within 7 days prior to outpatient surgery confirming that the necessity for the procedure is still present and that the H & P is still current. The physician uses his/her clinical judgment based on his/her assessment of the patient’s condition, and any comorbidities, in relation to the surgery to be performed, when deciding what depth of assessment needs to be performed and what information needs to be included in the update note; AND

The physician or other individual qualified to perform the H & P writes an update note addressing the patient’s current status and/or changes in the patient’s status,

physical examination and medical history be done for each patient no more than 30 days before or 24 hours after admission or registration by a physician (as defined in section 1861(r) of the Act), an oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy. Verify whether the bylaws require the H&P be completed prior to surgery or a procedure requiring anesthesia services.

Review the hospital’s policy, if any, to determine whether other qualified licensed individuals are permitted to conduct H&Ps to ensure that it is consistent with the State’s scope of practice law or regulations.

Verify that non-physicians who perform H&Ps within the hospital are qualified and have been

regardless of whether there were any changes in the patient’s status, within 7 days prior to the outpatient surgery. The update note must be on or attached to the H & P; AND

The H & P, including all updates and assessment, must be included in the patient’s medical record, except in emergency situations, prior to surgery.

If a H & P meets all these requirements prior to outpatient surgery, the H & P meets all the provisions of the regulation with regard to meeting the time restrictions on the currency of the H & P.

An H & P performed more than 30 days prior to hospital admission/outpatient surgery does not comply with the currency requirements and a new H & P must be performed.

An H & P performed

credentialed and privileged in accordance with the hospital’s policy.

Review a sample of inpatient and outpatient medical records that include a variety of patient populations undergoing both surgical and non-surgical procedures to verify that:

– There is an H&P that was completed no more than 30 days before or 24 hours after admission or registration, but, in all cases, prior to surgery or a procedure requiring anesthesia services; and– The H&P was performed by a physician, an oromaxillofacial surgeon, or other qualified licensed individual authorized in accordance with State law and hospital policy.

Interpretive Guidelines 482.22(c)(5)(ii)The Medical Staff bylaws must include a requirement that when a medical history andphysical examination has been completed within 30 days before admission or registration, an updated medical record entry must be completed and documented in the patient's medical record

more than 7 days prior to admission/outpatient surgery that does not meet the above currency criteria does not comply with the requirements and a new H & P must be performed.

All or part of the H & P may be delegated to other practitioners in accordance with State law and hospital policy, but the MD/DO must sign the H & P and as applicable, the update note and assume full responsibility for the H & P. This means that a nurse practitioner or a physician assistant meeting these criteria may perform the H & P, and/or the update assessment and note. (Update assessments and update notes are considered part of the H & P.)

Survey ProceduresDetermine that the medical staff bylaws require a physical examination and medical history be done for each patient by an MD or DO or where appropriate, an oromaxillofacial surgeon, no more than 7 days before admission/outpatient surgery or 48 hours after admission but prior to surgery/outpatient

within 24 hours after admission or registration. The examination must be conducted by a licensed practitioner who is credentialed and privileged by the hospital’s medical staff to perform an H&P. In all cases, the update must take place prior to surgery or a procedure requiring anesthesia services. Theupdate note must document an examination for any changes in the patient's condition since the patient's H&P was performed that might be significant for the planned course of treatment. The physician or qualified licensed individual uses his/her clinical judgment, based upon his/her assessment of the patient’s condition and co-morbidities, if any, in relation to the patient’s planned course of treatment to decide the extent of the update assessment needed as well as the information to be included in the update note in the patient’s medical record.

If, upon examination, the licensed practitioner finds no change in the patient's conditionsince the H&P was completed, he/she may

surgery. (However, the medical staff bylaws may allow the currency methodology and/or the delegation of this responsibility as discussed in the above interpretation.)

indicate in the patient's medical record thatthe H&P was reviewed, the patient was examined, and that "no change" has occurred in the patient's condition since the H&P was completed (71 FR 68676). Any changes in thepatient’s condition must be documented by the practitioner in the update note and placedin the patient’s medical record within 24 hours of admission or registration, but prior to surgery or a procedure requirement anesthesia services. Additionally, if the practitioner finds that the H&P done before admission is incomplete, inaccurate, or otherwise unacceptable, the practitioner reviewing the H&P, examining the patient, and completing the update may disregard the existing H&P, and conduct and document in the medical record a new H&P within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia.

Survey Procedures §482.22(c)(5)(ii)

Review the medical staff bylaws to determine whether they include

provisions requiring that, when the medical history and physical examination was completed within 30 days before admission or registration, an updated medical record entry documenting an examination for changes in the patient's condition was completed and documented in the patient's medical record within 24 hours after admission or registration.

Determine whether the bylaws require that, in all cases involving surgery or a procedure requiring anesthesia services, the update to the H&P must be completed and documented prior to the surgery or procedure.

In the sample of medical records selected for review, look for cases where the medical history and physical examination was completed within 30 days before admission or

registration. Verify that an updated medical record entry documenting an examination for any changes in the patient's condition was completed and documented in the patient's medical record within 24 hours after admission or registration. Verify that in all cases involving surgery or a procedure requiring anesthesia services, the update was completed and documented prior to the surgery or procedure.

§482.22(c)(6) Include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges.

Interpretive GuidelinesAll patient care is provided by or in accordance with the orders of a practitioner who meets the medical staff criteria and procedures for the privileges granted, who has been granted privileges in accordance with those criteria by the governing body, and who is working within the scope of those granted privileges.

Privileges are granted by the hospital’s governing body to individual practitioners based

Interpretive GuidelinesAll patient care is provided by or in accordance with the orders of a practitioner who meets the medical staff criteria and procedures for the privileges granted, who has been granted privileges in accordance with those criteria by the governing body, and who is working within the scope of those granted privileges.

Privileges are granted by the hospital’s governing body to individual practitioners basedon the medical staff’s review of that individual practitioner’s qualifications and the medical staff’s recommendations for that individual practitioner to the

on the medical staff’s review of that individual practitioner’s qualifications and the medical staff’s recommendations for that individual practitioner to the governing body.

Survey Procedures Verify that the

medical staff bylaws contain criteria for granting, withdrawing, and modifying clinical privileges to individual practitioners of the medical staff and that a procedure exists for applying these criteria.

Verify that practitioners who provide care to patients are working within the scope of the privileges granted by the governing body.

governing body.

Survey Procedures Verify that the medical

staff bylaws contain criteria for granting, withdrawing, and modifying clinical privileges to individual practitioners of the medical staff and that a procedure exists for applying these criteria.

Verify that practitioners who provide care to patients are working within the scope of the privileges granted by the governing body.